Spondyloarthropathies and ankylosing spondylitis Flashcards
Define spondyloarthritis.
Spondyloarthritis is a type of arthritis that attacks the spine and, in some people, the joints of the arms and legs. It can also involve the skin, intestines and eyes. The main symptom (what you feel) in most patients is low back pain.
What is the difference between axial spondyloarthritis vs ankylosing spondylitis?
‘Ankylosing spondylitis’ is used for patients who have developed changes at the sacroiliac joints. It takes on average 7yrs for inflammation to bony changes to occur.
‘Axial spondyloarthritis’ is a description is of inflammatory back pain, worse at night and at rest, and improving with movement
Name the types of spondyloarthritides (SpA).
- Acute anterior uveitis/iritis
- Reactive arthritis
- Psoriatic arthritis
- Enteropathy associated arthritis
- Juvenile SpA
- Undifferentiated SpA
- Ankylosing spondylitis is the most severe form
What is the epidemiology of SpA?
3:1 M>F
Usually presents in 20-30yo
Which SpAs are predominantly axial vs predominantly peripheral?
- Psoriatic, reactive, undifferentiated and IBD-related are predominantly peripheral
- Ankylosing spondylitis and non-radiographic axial SpA are axial
Axial spondyloarthritis is the same as ankyloising spondylitis.
Which gene is most associated with SpA?
HLA-B27 - present in 90% of those who have SpA and in 10% of those who do not have SpA
How does pathophysiology of RhA differ from SpA?
RhA - there is inflammation and cartilage erosion
SpA - there is inflammation and cartilage erosion AND ossification (subsequent repair)
If the x-ray is negative for sacroiliac joint involvement in ankylosing spondylitis but suspicion for AS remains high, what is the next step?
MRI - signs of early inflammation involving sacroiliac joints (bone marrow oedema) confirm the diagnosis of AS and prompt further treatment.
What may be seen in SpA on spirometry and why?
Spirometry may show a restrictive defect due to a combination of pulmonary fibrosis, kyphosis and ankylosis of the costovertebral joints.
What are the features of ankylosing spondylitis on examination?
reduced lateral flexion
reduced forward flexion - Schober’s test - a line is drawn 10 cm above and 5 cm below the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible
reduced chest expansion
skin and eye signs may be present
What classification is used for diagnosis of SpA?
ASAS
e.g. back pain for >3months + <45yo + HLA-B27 + FH of SpA + elevated CRP = SpA
NB: features such as dactylitus, psoriasis etc can be past or present
What are the features of ‘inflammatory’ back pain?
- Age of onset <40yo
- Insidious
- Improvement with exercise
- No improvement with rest
- Pain at night (with improvement on getting up)
Inflammatory back pain if at least 4 of 5 present.
What is the most obvious abnormality?
Sacroiliac joint narrowing - normal pelvis shown below
What are the radiograph findings in ankylosing spondylitis?
- sacroiliitis: subchondral erosions, sclerosis
- squaring of lumbar vertebrae
- ‘bamboo spine’ (late & uncommon)
- syndesmophytes: due to ossification of outer fibers of annulus fibrosus
- chest x-ray: apical fibrosis
What is shown?
Dactylitis with some psoriatic plaques
Give some examples of acute enthisitis presentations.
- Acute painful shoulder with painful arc
- Acute lower leg pain (Achilles tendinitis)
- Painful ankle/heel (plantar fasciitis)
What is shown?
Enthesitis at right heel - can also be shown by T1 MRI
What is shown?
Palmar pustulosis - skin manifestation of SpA
What is shown?
Keratoderma Blenorrhagicum - commonly seen in reactive arthritis on the soles or palms of hands
List 4 skin manifestations of SpA.
- Palmar pustulosis
- Keratoderma blenorrhagicum
- Erythema nodosum
- Pyoderma gangrenosum (IBD related)
What are the features of iritis in SpA?
Acute onset, unilateral eye pain with spontaneous remission but recurrent. Linked to HLA-B27.
Is SpA always seen on radiography?
Not in early stages, but later it can progress to radiographic stages
What is the management of SpA?
- NSAIDs - first line
-
Physiotherapy - core strength, posture training, gait assessment, spinal stretches
- Encourage regular exercise such as swimming
- Joint injections with corticosteroids are sometimes done
- cDMARDs - only in peripheral disease
- bDMARDs e.g. TNF-a inhibitors
- Surgery - wedge resection to correct dorsal kyphosis or lumbar lordosis
How do NSAIDs work?
Inhibit COX enzymes, which ar involved in synthesis of prostaglandins and thromboxanes
COX-2i are usually used in SpA but they come with increased thrombosis risk
Are cDMARDs (sulfasalazine, methotrexate) useful in axial SpA?
No - only have a role in peripheral disease
Which disease activity scores are used in SpA?
BASDAI
ASDAS
Which bDMARDs are used in SpA?
- TNF alpha blockers
- IL-17a
- IL-23 inhibitors
- JAK- inhibitors
What are the ‘A’s of ankylosing spondylitis?
- Apical fibrosis
- Anterior uveitis
- Aortic regurgitation
- Achilles tendonitis
- AV node block
- Amyloidosis
- and cauda equina syndrome
- peripheral arthritis (25%, more common if female)
Compare and contrast cDMARD vs biologic DMARDs.
What are syndesmophytes seen on XR in AS?
Syndesmophytes are bony growths that often occur in the spine and can cause fusion of the joints
What is adlimumab and how often is it taken in AS?
Adalimumab (anti-TNF alpha antibody) 40mgs every other week
Which investigations must be done prior to starting TNF-alpha blockers?
Serology for:
- hepatitis B and C
- HIV
TB quantiferon
Any active infection must be treated first. HIV is not a contraindication to use as long as it is well controlled.
What are the clinical features of juvenile idiopathic arthritis?
- >6 weeks of
- Joint pain
- Joint swelling
- Fever - high spiking fevers, at least 2/day for 2 weeks
- Morning stiffness
- Salmon coloured rash + Koebner’s phenomenon (appear when skin is scratched)
What investigations are used for diagnosing JIA?
- FBC - reduced Hb, high plt
- ESR, CRP - may be raised
- ANA - may be positive in the oligoarticular type but not systemic
- RF - sometimes positive
- Ferritin - may be high in systemic disease
MOA of infliximab/adalimumab?
Anti TNF-a
MOA secukinumab?
Anti IL-17
What questionnaire is used for monitoring AS disease?
BASDAI
What criteria is used to diagnose adult-onset Still’s disease?
Yamaguchi
MOA ustekinumab?
Anti IL-12 and IL-23 (used for psoriasis)
What type of view of the pelvis is used to assess the SIJ?
Ferguson view
What is the use of DMARDs in AS?
No use except for peripheral disease
What type of buttock pain is seen in sacroiliitis?
Alternating buttock pain
